Not long ago I had occasion to visit a new doctor, as the one I usually saw was out of town. At the time I was experiencing a rather intense back pain. He stood at his computer taking notes on what I was saying, rarely looked at me, did not examine the location of my pain and quickly ordered an MRI.
I was in his office for not much more than 10 minutes and thought I had been treated almost dismissively.
As documented in Sandeep Jauhar’s Doctored: The Disillusionment of an American Physician, the current pressures upon doctors explain why this is not an uncommon experience. The way managed care operates, insurance companies exert enormous control over medical practices. It is the new reality of medicine in this country today.
Insurance companies don’t reimburse doctors a great deal for spending time with patients. But they do for ordering stress tests, MRIs and CT scans (X-rays from several angles). This often leads to unnecessary testing, spending less time with patients and seeing as many as possible.
Are the tests worth the cost? Consider the evidence. The United States ranks 45th in life expectancy, near the last in infant mortality, and “in last place in terms of health care quality, access, and efficiency among major industrialized countries.”
Jauhar laments: How limited our interactions with patients, I thought. We see them for a few minutes, then pen a quick summary and leave directions for the nurses to follow. To whom are we speaking in these inky chart drizzles? Doctors, patients, a phantom lawyer?
Medical lapses and fear of lawsuits from diagnostic error requires doctors to take out medical malpractice insurance. The cost of these policies is prohibitive. Then there is all the paperwork doctors must complete each day. Jauhar writes:
American doctors spend almost an hour on average each day, and $83,000 per year—four times their Canadian counterparts—dealing with the paperwork of insurance companies); fear of lawsuits; runaway malpractice liability premiums; and finally, the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government
To compensate for his relatively stagnant income Jauhar begins to take on outside jobs. He speaks in behalf of a pharmaceutical company that makes a heart medication he prescribes and moonlights on weekends and evenings reading medically unnecessary cardiac stress and cardiogram tests for a “shady” physician.
The extra money helps to pay the rent for his apartment, schooling for his son, and needs of his pregnant wife. All this takes a toll on his family, to say nothing of Jauhar himself. He notes he was trained to be a caregiver and not a businessman “The constant intrusion of the marketplace has created serious and deepening anxiety in our profession.”
Burnout is an increasingly frequent response to this situation, with approximately a third of physicians surveyed admitting feeling that way, while others are giving up their practice entirely. Jauhar also comments that only 6% of physicians reported “positive moral” in a 2008 survey. In another study, 30 to 40 percent of practicing physicians said they would not choose to enter the medical profession if they were deciding on a career now.
Jauhar doesn’t offer many solutions to these fee-for-service problems. His one suggestion is to hire doctors as employees as they do at the Mayo and Cleveland Clinics. He believes this will take away the financial incentives to overtest.
After reading Doctored, I don’t think I will ever view the relationship I have with my doctor the same way. Is the test he is ordering necessary? Is the medication he is prescribing going to benefit me? Why has he spent so little time with me?
As I look back on some of the tests and medications he has ordered, I view them in a new light. The tests revealed nothing abnormal, the drugs sometimes did more harm than good. I wonder why he ever ordered them in the first place and I am not sure.
When I was a young boy, my doctor always made a house call when I was sick. Today that is almost unheard of. In 1930 40% of all doctor-patient visits were house calls. Today the proportion has dwindled to less that 1%.
Now the encounters I have with my doctor, often take place online or mediated through his nurse and it often takes weeks and sometimes a month to actually arrange an appointment with him.
Jauhar concludes: Most of us went into medicine to help people, not to follow corporate directives or to maximize income. We want to practice medicine the right way, but too many forces today are propelling us away from the bench or the bedside. No one ever goes into medicine to do unnecessary testing. However, this sort of behavior is rampant.
